Definition:• The Baby Friendly Hospital Initiative was introduced in 1991 by the World Health Organization/United Nations Childrens Fund (WHO/UNICEF) to promote, protect and support breastfeeding in the hospital or birth setting. A key element in this promotion and support is outlined in their Ten Steps to Successful Breastfeeding. To date, approximately 19,000 hospitals and birth centers in about 125 countries have received the "Baby Friendly" designation.
CRITERIATen steps to successful breastfeeding recommended by code of practice of WHO/ UNICEF :-• Have a written breastfeeding policy that is routinely communicated to all health care staff.• Train all health care staff in skills necessary to implement this policy.• Inform all pregnant women about the benefits and management of breastfeeding.• Help mothers initiate breastfeeding within one half-hour of birth.• Show mothers how to breastfeed and maintain lactation,even if they should be separated from their infants.
• Give newborn infants no food or drink other than breastmilk, unless medically indicated.• Practice rooming in - that is, allow mothers and infants to remain together 24 hours a day.• Encourage breastfeeding on demand.• Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.• Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Step 1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
Breastfeeding policy Why have a policy?• Requires a course of action and provides guidance• Helps establish consistent care for mothers and babies• Provides a standard that can be evaluated
Breastfeeding policy What should it cover?• At a minimum, it should include: – The 10 steps to successful breastfeeding – An institutional ban on acceptance of free or low cost supplies of breast-milk substitutes, bottles, and teats and its distribution to mothers – A framework for assisting HIV positive mothers to make informed infant feeding decisions that meet their individual circumstances and then support for this decision• Other points can be added
Breastfeeding policy How should it be presented?It should be:• Written in the most common languages understood by patients and staff• Available to all staff caring for mothers and babies• Posted or displayed in areas where mothers and babies are cared for
Step 2. Train all health-care staff in skills necessary to implement this policy.
Areas of knowledge• Advantages of breastfeeding• Risks of artificial feeding• Mechanisms of lactation and suckling• How to help mothers initiate and sustain breastfeeding
• How to resolve breastfeeding difficulties• How to assess a breastfeed• Hospital breastfeeding policies and practices• Focus on changing negative attitudes which set up barriers
Step 3. Inform all pregnant women about the benefits of breastfeeding.
Antenatal education should include:• Benefits of breastfeeding• Early initiation• Importance of rooming-in (if new concept)• Importance of feeding on demand• Importance of exclusive breastfeeding• How to assure enough breastmilk• Risks of artificial feeding and use of bottles and pacifiers (soothers, teats, nipples, etc.)
• Basic facts on HIV• Prevention of mother-to-child transmission of HIV (PMTCT)• Voluntary testing and counselling (VCT) for HIV and infant feeding counselling for HIV+ women• Antenatal education should not include group education on formula preparation
Step 4. Help mothers initiate breastfeeding within a half-hour of birth.
New interpretation of Step 4 in the revised BFHI Global Criteria (2006):Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed.”
Early initiation of breastfeeding for the normal newborn Why?• Increases duration of breastfeeding• Allows skin-to-skin contact for warmth and colonization of baby with maternal organisms• Provides colostrum as the baby’s first immunization• Takes advantage of the first hour of alertness• Babies learn to suckle more effectively• Improved developmental outcomes
Early initiation of breastfeeding for the normal newborn How?• Keep mother and baby together• Place baby on mother’s chest• Let baby start suckling when ready• Do not hurry or interrupt the process• Delay non-urgent medical routines for at least one hour
Protein composition of human colostrum and mature breast milk (per litre)Constituent Measure Colostrum Mature Milk (1-5 days) (>30 days)Total protein G 23 9-10.5Casein mg 1400 1870α-Lactalbumin mg 2180 1610Lactoferrin mg 3300 1670IgA mg 3640 1420
• Step 5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants
Contrary to popular belief, attaching the baby on the breast• is not an ability with which a mother is [born…]; rather it is a learned skill which she must acquire by observation and experience.
Supply and demand Milk removal stimulates milk production. The amount of breast milk removed at each feed determines the rate of milk production in the next few hours. Milk removal must be continued during separation to maintain supply.
• Step 6. Give newborn infants no food or drink other than breast milk unless medically indicated
• Decreased frequency or effectiveness of suckling• Decreased amount of milk removed from breasts• Delayed milk production or reduced milk supply• Some infants have difficulty attaching to breast if formula given by bottle
Acceptable medical reasons for supplementation or replacementInfant conditions:• Infants who cannot be BF but can receive BM include those who are very weak, have sucking difficulties or oral abnormalities or are separated from their mothers.• Infants who may need other nutrition in addition to BM include very low birth weight or preterm infants, infants at risk of hypoglycaemia, or those who are dehydrated or malnourished, when BM alone is not enough.• Infants with galactosemia should not receive BM or the usual BMS. They will need a galactose free formula.• Infants with phenylketonuria may be BF and receive some phenylalanine free formula.
Maternal conditions:• BF should stop during therapy if a mother is taking anti-metabolites, radioactive iodine, or some anti-thyroid medications.• Some medications may cause drowsiness or other side effects in infants and should be substituted during BF.• BF remains the feeding choice for the majority of infants even with tobacco, alcohol and drug use. If the mother is an intravenous drug user BF is not indicated.• Avoidance of all BF by HIV+ mothers is recommended when replacement feeding is acceptable, feasible, affordable, sustainable and safe. Otherwise EBF is recommended during the first months, with BF discontinued when conditions are met. Mixed feeding is not recommended.
Maternal conditions (continued)::• If a mother is weak, she may be assisted to position her baby so she can BF.• BF is not recommended when a mother has a breast abscess, but BM should be expressed and BF resumed once the breast is drained and antibiotics have commenced. BF can continue on the unaffected breast.• Mothers with herpes lesions on their breasts should refrain from BF until active lesions have been resolved.• BF is not encouraged for mothers with Human T-cell leukaemia virus, if safe and feasible options are available.• BF can be continued when mothers have hepatitis B, TB and mastitis, with appropriate treatments undertaken.
Step 7. Practice rooming-in — allow mothers and infants to remain together — 24 hours a day.
• Rooming-in• A hospital arrangement where a mother/baby pair stay in the same room day and night, allowing unlimited contact between mother and infant
Rooming-in Why?• Reduces costs• Requires minimal equipment• Requires no additional personnel• Reduces infection• Helps establish and maintain breastfeeding• Facilitates the bonding process
• Breastfeeding on demand:• Breastfeeding whenever the baby or mother wants, with no restrictions on the length or frequency of feeds
On demand, unrestricted breastfeeding Why?• Earlier passage of meconium• Lower maximal weight loss• Breast-milk flow established sooner• Larger volume of milk intake on day 3• Less incidence of jaundice
Step 9. Give no artificial teats or pacifiers (also called dummies and soothers) to breastfeeding infants.
Alternatives to artificial teats• cup• spoon• dropper• Syringe
Definition:The feeding of an infant or young child with breast milk directly from female human breasts rather than from a baby bottle or other container.
Benefits to the BabyPerfect nutritionHigher IQComplete food for the firstsix monthsEmotional bondingPrevents infectionsPrevents chronic diseasesEasily digested
Benefits to the MotherReduces post deliverybleeding and anemiaHelps delay next pregnancyProtective effect againstbreast and ovarian cancerHelps to loose weightEmotional bondingNeeds no preparation
Breastfeeding in the Correct PositionMilk producing glandsLactiferous canaliculiLactiferous sinusesMyoepithelial tissueAdipose tissue
Signs of Correct Attachment Mouth wide open Lower lip is turned outside Chin touching the breast Black part of the breast not visible below the lower lip Large black portion of breast and nipple including milk collecting ducts are inside baby’s mouth Tongue under the teat
Incorrect Sucking PositionMouth is not wide openChin is away from the breastBaby is sucking only nippleMost black portion of thebreast is outside the baby’smouthTongue away from the teat
Causes of Incorrect Attachment• Use of feeding bottles. Leads to nipple confusion• Inexperienced mother• Functional difficulty with the mother or the baby• Lack of skilled support
Breastmilk Production The Prolactin reflex Sensory ImpulsesProlactin in blood from nipple More prolactin secreted at night Secreted after feed to Baby sucking produce next feed Suppresses ovulation
The Feeling of “Not Enough Milk”Not True. Just a perceptionReinforce mothers:Self confidence is mustEnsure frequent sucklingEnsure effective suckling
Conclusion Exclusive Breastfeeding for First Six MonthsBeing Successful-• Initiate breastfeeding as early as possible within one hour of birth.• Do not give the baby any prelacteal feeds• No bottles, artificial teats or pacifier• Breastfeeding on demand at least 8-10 times in a day and at night a• Breastfeed in a correct position• Build mother’s confidence to sustain good milk supply and alleviate feeling of not enough milk.
• Newborn deserves the best Nutrition, Improved Survival, Optimum Development and Healthy Life• Breastfeeding can do this miracle !!!
INDICATORS OF ADEQUACY :-Adequacy of breast feeding is indicated and established by the following:-• Audible feeding sound while swallowing• Let down sensation in mother’s breast• Breast is full before the feed and soft after feed• Wet nappies 6 or more in 24 hrs• Frequant soft bowel movements 3 to 8 times in 24 hrs• Average weight gain of 18-30 gm/day• Baby sleeps well and doesnot cry frequently• Baby has good muscle tone and healthy skin
IMMUNOLOGIC SPECIFICITY• Protection against pathogens & allergens• Kills pathogenic organisms or modifies their growth• Stimulates epithelial maturation for future defence• First immunization• Protection against common respiratory and intestinal diseases
IMMUNOLOGIC SPECIFICITY• Colostrum = Baby’s first vaccination• Less risk of illness such as: Ear infections, pneumonia, crohn’s disease and other bowel illnesses, stomach flu and other intestinal illnesses, ear infections, childhood cancers, diabetes, arthritis, allergies, asthma and eczema
PERFECT FOOD FOR BABIES• Just the right amount of nutrients in the right proportions• Over 200 components in human milk• Composition of breast milk: -Live cells, fat, carbohydrates, proteins, vitamins, minerals -Less fat than most other mammals -More lactose than other mammals
BREAST MILK COMPOSITION• Fat (4% concentration provides up to 50% of caloric needs, cholesterol levels constant, lipolytic enzymes aid in fat digestion)• Carbohydrates (lactose = milk sugar predominantly in human milk, 7% concentration provides up to 40% caloric needs, essential for development of CNS, enhances calcium & iron absorption)
BREAST MILK COMPOSITION• Carbohydrates (Bifidus factor = growth factor present only in human milk required for establishing an acidic environment in the gut to inhibit growth of bacteria, fungi and parasites)• Protein -Lactoferin => Isolates external iron -Secretory IGA => Most important immunoglobulin, breast milk = only source for first 6 weeks
Why some mothers choose formula vs. breast milk• Distressed by physical discomfort of early breastfeeding problems.• Convenience issues• Pressures of employment/school• Worries that breast shape will change• Formula manufacturers manipulate people through their ads• Doctors and nurses need more lactation training
Why some mothers choose formula vs. breast milk• Moms given very little time to adjust to changes of postpartum• Family demands• Non-supportive family/health professionals• Embarrassment• Lack of confidence in self• Feeling that one cannot produce enough milk
Mother’s milk vs. formula milk• Human milk is designed to support the development of large brains, capable of processing and storing lots of information.• Cows milk is designed to support functions, like constant grazing.
Illness Relative risk• Allergies, eczema 2 to 7 times• Urinary tract infections 2.6 to 5.5 times• Inflammatory bowel disease 1.5 to 1.9 times• Diabetes, type 1 2.4 times• Gastroenteritis 3 times• Hodgkins lymphoma 1.8 to 6.7 times• Otitis media 2.4 times• Haemophilus influenzae meningitis 3.8 times• Necrotizing enterocolitis 6 to 10 times